The Importance of Speaking Up on the Front Lines

November 18, 2022
Why it matters

A review of Constellation’s malpractice claim data reveals that breakdowns in team communication are a top driver of harm and malpractice claims. At the core of team communication is the ability to speak up when a team member knows or suspects something that could potentially harm a patient or senior living resident. Speaking up can help reduce the chance of adverse events such as medication errors, wrong site surgery and other potentially preventable harm events. Barriers between clinicians and care team members can lead to discomfort in speaking up. Despite their interrelated roles and frequent interactions, most barriers exist between physicians and nurses.1

Nurses stay silent

The Silent Treatment, a study of 6,500 nurses, found that although 85% of respondents acknowledged that a safety tool alerted them to a missed problem that might have caused patient harm, over half (58%) stayed silent about it.2 The majority said disrespect prevented them from speaking up.

“According to the research, the safety tools and checklists that have become mandatory in organizations are not sufficient to reduce errors and harm. Disrespectful coworkers, dysfunctional teams and poor communication processes hinder the effectiveness of these tools.”

Kristi Eldredge, Constellation Sr. Risk Consultant
Hierarchy and unprofessional behavior

Health care environments are frequently characterized by a hierarchical culture with physicians at the top. When a hierarchy dynamic exists, the collaboration required to enable safe care may be negatively impacted. Physicians may feel that the culture is collaborative and that there is open communication with the nursing team. In contrast, nurses and other direct care team members may see barriers to communicating with physicians.

Disruptive and unprofessional behavior by those at the top of a hierarchical pyramid creates fear and hinders communication. The research shows that issues from unresolved conflict between physicians and nurses adversely affect care.

“Poor communication postoperatively because of the disruptive reputation of the surgeon resulted in delayed treatment, aspiration and eventual demise” was one example provided by a nurse who participated in the study and is a tragic example of the outcome of disruptive behavior and silence.

Next steps: Educating nurses and physicians

It is essential that education about how to speak up be introduced early in medical and nursing training. Nursing educators should teach new students about their role in intervening in any incidents of potential harm and reporting unprofessional behaviors. Doing so may help stop the unacceptable notion that “it’s just the way it is here,” which can lead to adverse events and harm.

Leaders in both medicine and nursing have implemented plans to promote a collaborative rather than competitive agenda in health care. Nurse leaders should talk openly about speaking up. An excellent way to talk about speaking up is to provide real-life examples in which ignoring problems can cause harm. Dr. Amy Edmonson, an expert on psychological safety, recommends that leaders check in with their teams regularly by asking for feedback on questions, like those found in Constellation’s Speak Up Survey.

It takes dedicated, professional and courageous humans to speak up, and ultimately, the individual nurse is responsible. Moral courage may not be something every individual is born with, but in the proper environment, it can be developed over time.

A call to action might include the following:

A structured communication process and the right tools can improve care and mitigate OB-related harm:

  • Do not delay. Make the decision ahead of time that you will speak up if you witness a potential for patient harm. This will allow you to act immediately.
  • Understand that YOU are part of your unit’s culture. Choose to accept your responsibility. In the absence of a leader, any and every care team member can step up and intervene to ensure safety.
  • Remember your ethical responsibility as a nurse. All health care professionals have an ethical responsibility to make decisions based on what is best for patients—not themselves—even if it is uncomfortable, embarrassing or if there are consequences.
  • Acknowledge your fear and speak up anyway. Become comfortable with being uncomfortable.
  • Speak to your manager or your professional leader. If you are unable to speak up directly, your manager is unreceptive to your concerns, or you feel your concern is not being heard, you should refer to your employer’s policies and procedures for supporting staff who speak up.
  • Do not allow your concern to spill over into anger. Try to be as objective and constructive as possible.
How Constellation can help: The HEAL Prepare Toolkit

Constellation’s HEAL Prepare Toolkit will help assess your team’s readiness to communicate following a harm event and help you get to best practices. The Toolkit includes a unit on communication and culture and contains assessments, best practices, sample tools and coaching. Start your journey by taking the HEAL Assessment, and then the Action Plan will guide you through the Toolkit’s four units: (1) culture, (2) event response, (3) communicating after harm events, and (4) moving forward. Sign in to Constellation to access the HEAL Prepare Toolkit found in Risk Resources.

Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.


1O’Daniel M, Rosenstein AH. Professional Communication and Team Collaboration. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 33. Accessed September 12, 2022
2Maxfield D, Grenny J, Lavandero R, et al. The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives. Provo, UT: VitalSmarts; 2011.

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